SOUTH COUNTY PAIN & REHAB
Maureen D. Miner. M.D.
Diplomate, American Board of Physical Medicine & Rehabilitation
Diplomate, American Board of Pain Medicine
Sub-Specialty Board Certified, Spinal Cord Medicine
Qualified Medical Evaluator
 
  7091 Monterey St., Suite A
Gilroy, CA 95020
Phone: (408) 842-9296
FAX: (408) 842-6878
Date 2020-05-14 Physician MAUREEN D. MINER, MD
Caller Phone Fax
Primary
Complaint
✔ Workers Compensation   Private Insurance   Medicare /2ndInsurance   Self- Pay
Patient’s
Name


Address 		AHMED, SALMA 


400 W. Winton Avenue
Hayward, CA 94545

Claim/Policy#

WCAB#

Date of Injury

Soc Sec #
1402060 
ADJ13074170 
12/02/2019 
604-44-6068 
Phone
(home/cell) 		510-504-3767  Phone
(work) 		  Birth Date 01/09/1962 


Adjuster Name


INS. Address 		Jared R. Nowak   

Employer Name


Address

 Institute on Aging 


 
Church Mutual Insurance Co.
P.O. Box 342
Merrill, WI 54452 
Phone 800-554-2642 ext. 4205  Fax 714-539-4651  Phone   Fax  
Appt. TYPE   QME Panel   QME Re–Eval   QME
Applicant		 ✔ AME   Med legal   Consult ONLY   Consult&Treat   EMG/NCS
Appt. DATE: 0000-00-00  Appt. TIME  
Interpreter required?   No   Yes Agency/Language   

Referring Physician
Address 		 
Case Manager

Address
   
Phone   Fax   Phone   Fax  

Applicant Attorney
Address 		Steve Franco, Esq. 


Defense Attorney
Address 		Paul G. Wolfe, Esq. 
Franco Munoz, A Professional Corp. 
825 Washington Street, Ste. 211
Oakland, CA 94607 		Stander, Reubens, Thomas, Kinsey 
7250 Redwood Blvd., Ste. 370
Navato, CA 94945
Phone 510-257-4141  Fax 510-257-4110  Phone 415-892-7676  Fax 415-892-7436 
PROVIDE MEDICAL RECORDS 3 weeks IN ADVANCE
PLEASE DO NOT SEND ORIGIANALS OR CD’S
NO SHOW FEE: $300.00
  
ACKNOWLEDGE ABOVE WITH YOUR INITIALS_____
AND FAX BACK TO OUR OFFICE. THANK YOU